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ED Ultrasound Rob Hall MD Oral Presentation PGY4 Emergency Medicine October 30 th, 2003

Mar 26, 2015

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ED Ultrasound Rob Hall MD Oral Presentation PGY4 Emergency Medicine October 30 th, 2003 Slide 2 ED echo ( Eddie ) ED ultrasound WHY SHOULD WE? Slide 3 Ultrasound imaging enhances the physician's ability to evaluate, diagnose, and treat emergency department (ED) patients. Because ultrasound imaging is often time- dependent in the acutely ill or injured patient, the emergency physician is in an ideal position to use this technology. Focused ultrasound examinations provide immediate information and can answer specific questions about the patient's physical condition. Such bedside ultrasound imaging is within the scope of practice of emergency physicians. Slide 4 CAEP Position Statement: Feb 1999 Ultrasound should be available 24 hours per day for emergency patients, particularly for those being evaluated for cardac tamponade, abdominal aortic aneurysm, abdominal trauma, and ectopic pregnancy. A focused or limited bedside Emergency Department ultrasound should be available, performed by technicians, radiologists, or appropriately trained, qualified and experienced Emergency Physicians. Slide 5 Who is doing ED ultrasound in the USA? Counselman. Acad Emerg Med 2000 Mail out survery 80% response rate 95% of emergency medicine training programs teaching and using ultrasound Accounting for response bias --------- 75% of programs Conclusion: ED ultrasound is mainstay in US emerg programs Slide 6 What do all these places have in common? Winnipeg Lethbridge Kelowna Lillooet Abbotsford Vancouver Victoria Nanaimo Fredericton Sacre Coeur Granby St-Paul Monmagny Montreal Ottawa Torondo Windsor Brampton Sarnia Kingston Parry Sound Huntsvile Sault Sainte Marie Slide 7 What do all of these specialists have in common? Slide 8 Main objective: literature review of ED ultrasound 4 Primary Indications AAA CardiacFAST Pregnancy Slide 9 Main objective: literature review of ED ultrasound 4 Primary Indications AAA CardiacFAST Pregnancy Slide 10 AAA: objectives Is there literature supporting ED ultrasound to detect AAAs? How much training is required be accurate? Slide 11 AAA: general information Ultrasound done by radiology is nearly 100% sensitive for the detection of AAA Ultrasound measurements correlate with CT and laparotomy measurements w/I 2-3mm Physical examination is unreliable: Lederle JAMA 1999 3.0-3.9cm29% sensitivity 4.0-4.9cm50% sensitivity > 5.0cm75% sensitivity Slide 12 AAA: 6 prospective studies StudySizeTrainingSens. % (C.I.s) Spec.% (C.I.s) Accurracy (C.I.s) Jones 2003 N=668hrs98 (86-100) 100 (87-100) 99 (90-100) Rowland 2001 N=333 days100 (74-100) 100 (85-100) 100 (90-100) Kuhn 2000 N=683 days100 (87-100) 100 (91-100) 100 Mandavia 2000 N=4416hrs50 (15-70) 95 (79-98) 93 Lanoix 2000 N=204hrs100 (40-100) 100 (76-100) 100 Schlager 95 N=1116hrs100 Slide 13 AAA: 6 prospective studies StudySizeTrainingSens. % (C.I.s) Spec.% (C.I.s) Accurracy (C.I.s) Jones 2003 N=668hrs98 (86-100) 100 (87-100) 99 (90-100) Rowland 2001 N=333 days100 (74-100) 100 (85-100) 100 (90-100) Kuhn 2000 N=683 days100 (87-100) 100 (91-100) 100 Mandavia 2000 N=4416hrs50 (15-70) 95 (79-98) 93 Lanoix 2000 N=204hrs100 (40-100) 100 (76-100) 100 Schlager 95 N=1116hrs100 Slide 14 AAA Jones. Emergency Medicine 2003. Prospective N=66 scans for AAA Initial training was an 8 hour course covering four primary indications Gold standard = CT or laparotomy Results Sensitivity 98% (86-100) Specificity 100% (87-100) Accuracy 99% (90-100) Slide 15 AAA Khun. Ann Emerg Med 2000 Prospective, N=68 Training was 3 days (2hrs for AAA) Gold standard = radiologist review of video Results Sensitivity 100% (87-100) Specificity 100% (91-100) Accuracy 100% (no CI) Slide 16 AAA: conclusions Emergency Physicians can achieve accuracy in detection of AAAs with limited training Our scans should aim to be 95% accurate Slide 17 Main objective: literature review of ED ultrasound 4 Primary Indications AAA CardiacFAST Pregnancy Slide 18 Cardiac: objectives Can ED ultrasound be used to predict survival post cardiac arrest? Is there literature supporting ED ultrasound for the detection of pericardial effusions? LV function? Slide 19 Cardiac arrest and ED ultrasound Blaivas Acad Emerg Med 2001 Prospective, N=166 Cardiac standstill 0/136 survival Cardiac activity 20/33 survival Salen Acad Emerg Med 2001 Prospective, N=102 Standstill: 2/61 survival Cardiac activity: 11/41 survival ETC02 production was a better predictor Slide 20 Cardiac: conclusions There is insufficient evidence to prove that cardiac standstill is a reliable indicator of cardiac arrest survival Cardiac standstill should be considered in the decision to terminate resuscitation but should not be the sole criterion Slide 21 Cardiac: LV function Moore. Acad Emerg Med 2002 Looked at atraumatic hypotensive patients Prospective, N=51, cardiology as gold standard Ratings: normal (1), mod depressed (2), severely depressed (3) Kappa 0.61 (0.39-0.83) EP ratings Cardiologist ratings 123 11750 2792 3028 Slide 22 Cardiac: pericardial effusions StudyMethodTrainingSensSpecAccurac y Mandavia 2001 N=51516hrs96 (90-99) 98 (96-99) 97.5 (95-99) Mandavia 2000 N = 2816hrs100 (50-100) 100 (60-100) 100 Lanoix 2000 N=674hrs88 (47-99) 98 (90-99) 97 Ma 1995N=24510hrs + 20 exams 10099 Slide 23 Cardiac: pericardial effusions StudyMethodTrainingSensSpecAccurac y Mandavia 2001 N=51516hrs96 (90-99) 98 (96-99) 97.5 (95-99) Mandavia 2000 N = 2816hrs100 (50-100) 100 (60-100) 100 Lanoix 2000 N=674hrs88 (47-99) 98 (90-99) 97 Ma 1995N=24510hrs + 20 exams 10099 Slide 24 Cardiac: pericardial effusions Mandavia. Ann Emerg Med 2001 Prospective study, N=515 Training = 16hrs, 5hrs dedicated to echo Gold standard = blinded cardiologist interpretation All scans were clinically indicated Results: Technically adequate in 93% Sensitivity 96% (90-99) Specificity 98% (96-99) Accuracy 97.5% (95-99) Slide 25 Cardiac: conclusions Emergency Physicians can achieve accuracy in detection of pericardial effusion with limited training Our scans should aim to be 95% accurate Determination of LV function requires further study Slide 26 Main objective: literature review of ED ultrasound 4 Primary Indications AAA CardiacFAST Pregnancy Slide 27 Pregnancy: objectives How does ED ultrasound affect patient satisfaction? How does ED ultrasound affect ED flow? Is there literature supporting the accuracy of ED ultrasound in pregnancy? Slide 28 Pregnancy: patient satisfaction Krubel. Am J Emerg Med. 1998 Prospective; got ED ultrasound Survey of 96 ED visits Showed Improved overall satisfaction with ED care Improved satisfaction with tests performed Reduced desire for a second opinion Reduced anxiety after the ED visit Slide 29 Pregnancy: ED flow Remember the chart review we did last year: pregnancy related u/s Document IUP was found in 72% of initial ultrasounds ED ultrasound would likely be useful in 72% of patients Slide 30 Pregnancy: ED flow Rogerson. Acad Emerg Med ED RUQ ultrasound is associated with a reduced time to diagnosis and treatment of rupture ectopic pregnancies Retrospective review TimeED u/sRadiology u/s To Dx58 min (28-87)197 (162-232) To OR111 min (69-153)322 (270-364) Slide 31 Pregnancy: ED flow Blaivas. Acad Emerg Med 2000 Do emergency physicians save time when locating a live IUP with bedside ultrasound? Retrospective review of 1419 charts Length of stays ED ultrasound3hr 40min Rad ultrasound4hr 39min Absolute diff59 min, p=0.0001 Slide 32 Pregnancy: ED flow Burgher. Acad Emerg Med 1998 Before and after ED u/s introduction study Mean L.O.S. before: 234 min Mean L.O.S. after: 164 min Difference 70 min, p=0.0003 Shih. Ann Emerg Med Prospective; L.O.S. decreased when ultrasound showed an IUP ED ultrasound: mean L.O.S. 45 min Radiology ultrasound: mean L.O.S. 177min Slide 33 Pregnancy: conclusions ED ultrasound can improve ED flow ED ultrasound can improve patient satisfaction Slide 34 Pregnancy: detecting an IUP How accurate can ER docs be after minimal training? Is it safe? Slide 35 Pregnancy: detecting and IUP Studies look at sensitivity and specificity of detecting an IUP not an ectopic Specificity is therefore more important! IUP present IUP absent U/S shows IUP True Positive False Positive (BAD!!!!!!) U/S doesn t show IUP False Negative True Negative Slide 36 Pregnancy: 6 prospective studies StudySizeTrainingSens. % (C.I.s) Spec.% (C.I.s) Accurracy (C.I.s) Mandavia 2000 N=10116 hrs76 (61-99) 92 (76-96) 83% Lanoix 2000 N=334hrs100 (82-100) 90 (54-99.5) 97% Shih 1997 N=12524hrs +10exams 94% (82-98%) 100 (83-100) 96% Durham 1997 N=13624hrs + 10 exams 97% (91-97) Mateer 1995 N=15212hrs + 12 exams 99 (97-100) 93 (80-100) Jehle 1989N=40??97.5 Slide 37 Pregnancy: 6 prospective studies StudySizeTrainingSens. % (C.I.s) Spec.% (C.I.s) Accurracy (C.I.s) Mandavia 2000 N=10116 hrs76 (61-99) 92 (76-96) 83% Lanoix 2000 N=334hrs100 (82-100) 90 (54-99.5) 97% Shih 1997 N=12524hrs +10exams 94% (82-98%) 100 (83-100) 96% Durham 1997 N=13624hrs + 10 exams 97% (91-97) Mateer 1995 N=15212hrs + 12 exams 99 (97-100) 93 (80-100) Jehle 1989N=40??97.5 Slide 38 Pregnancy: detecting an IUP Shih. Ann Emerg Med 1997 Prospective, N=125 Training: 24hrs + 10 proctored exams Gold standard was formal ultrasound Some were transvag some transabd Results Sensitivity for IUP: 94% (C.I. 82-98%) Specificity for IUP: 100% (C.I. 83-100) Slide 39 Pregnancy: detecting an IUP Durham. Ann Emerg Med 1997 Prospective, N=136 Training: 24hrs + 20 proctored exams (variable) Gold standard: formal ultrasound Pre-defined possible ultrasound results and correlated ER interpretation vs formal ultrasound result Results showed overall 97% accurracy (91-97% C.I.) Slide 40 Pregnancy: detecting an IUP: Durham. Ann Emerg Med 1997 DiagnosisCorrectIncorrectAccuracy (95%C.I.) IUP with fetal pole 870100% (97-100) IUP FAST: variable sensitivity Melanson. Emerg Med Clinics 1998 Reviewed 30+ studies Summarized studies with > 250 scans Sensitivities ranged from 70-99% Specifici